Acute Coronary Syndrome

Question 1

Where to hear S1

Answer 1

5th intercostal space, left midclavicular line

Question 2

What are you hearing when you hear S1?

Answer 2

beginning of ventricular systole

Question 3

Where is it best to hear S2?

Answer 3

2nd intercostal space and L or R sternal border

Question 4

What are you hearing when you hear S2?

Answer 4

beginning of ventricular diastole

Question 5

Click heart sound

Answer 5

high pitched tone following S1- improper closing of the valve

Question 6

Snap heart sound

Answer 6

sharp sound following S2- typical with mitral stenosis

Question 7

What does a murmur indicate?

Answer 7

blood back flow through an incompletely closed valve

Question 8

What do you do when you hear a new murmur?

Answer 8

contact provider asap

Question 9

Main cause of CAD

Answer 9

atherosclerosis

Question 10

What causes atherosclerosis? (2)

Answer 10

• Repeated inflammatory response to artery wall (HTN, T2D, inflammatory diet)
• Repeat vascular injury to endothelium

Question 11

CAD path (4)

Answer 11

endothelial injury –> fatty streak –> plaque –> complex lesion

Question 12

What can happen to a complex lesion?

Answer 12

May rupture & produce a thrombus – activation of coagulation cascade & platelet aggregation !!!

Question 13

non-modifiable CAD risk factors (5)

Answer 13

	Family history
	Men > 45 years old
	Women > 55 years old
	Gender
	Race

Question 14

Modifiable CAD risk factors (9)

Answer 14

	Hyperlipidemia 
	Smoking, tobacco
	HTN, diabetes
	Metabolic syndrome 
	Physical inactivity
	Obesity
	High LDL
	Low HDL
	Resulting atherosclerosis

Question 15

What are CAD clinical manifestations dependent on?

Answer 15

Symptoms depend on location, degree of narrowed vessel, thrombus formation, and obstruction of blood flow to myocardium

Question 16

CAD clinical manifestations (2)

Answer 16

• angina pectoris

- MI

Question 17

What is stable angina?

Answer 17

Predictable & consistent pain occurring on exertion

Question 18

How is stable angina treated?

Answer 18

o Relieved by rest and nitroglycerin (sublingual  dilates coronary artery)

Question 19

unstable angina characteristics (4)

Answer 19

o Symptoms increase in frequency & severity, often at rest
o May NOT be relieved by rest and nitroglycerin
o EKG may be Normal, or T inversion
o Normal troponins

Question 20

What is silent ischemia?

Answer 20

o Objective evidence of ischemia but patient is asymptomatic

Question 21

which population is most at risk for silent ischemia?

Answer 21

elderly population

Question 22

Angina medical management –> which medication class is given for immediate alleviation of pain?

Answer 22

Nitrates

Question 23

angina medical management- nitrates (3)

Answer 23

• nitroglycerin
• nitrobid
• nitrostat

Question 24

angina medical management- beta blockers (2)

Answer 24

• metoprolol

- atenolol

Question 25

angina medical management- calcium channel blockers (2)

Answer 25

-amlodipine, diltiazem

Question 26

angina medical management- anti platelet medications (3)

Answer 26

o ASA, clopidogrel (Plavix), prasugrel (Effient)

Question 27

angina medical management- anticoagulants (5)

Answer 27

o Unfractionated heparin, enoxaparin, apixaban, rivaroxaban, fondaparinux,

Question 28

Nitroglycerin ointment steps (4)

Answer 28

1. Wear gloves when removing old application and applying new application to prevent the development of headache 2. Remove previous nitroglycerin ointment and applicator paper and fold in half before disposing in trash 3. Apply new ointment on a different site 4. Do not massage; secure, date time and initials

Question 29

CAD Prevention (5)

Answer 29

- lower cholesterol - stop smoking - lower BP - control T2D - increase activity

Question 30

What is an important question to ask when a male comes in with chest pain regarding their medications?

Answer 30

if they are on erectile dysfunction medications

Question 31

CAD diagnostic studies (6)

Answer 31

- 12 lead ECG - holter monitor - exercise tolerance test (stress test) - nuclear stress test/pharm stress test - echo - TEE

Question 32

What does the holter monitor detect?

Answer 32

dysrhythmias

Question 33

Exercise tolerance test (stress test) What does it do? what to monitor -stressed via ___ if patient cannot tolerate exercise

Answer 33

1. Exercise to increase demand on heart 2. Stressed via drugs (e.g., adenosine) if patient cannot tolerate exercise 3. Monitoring vital signs, ECG

Question 34

Nuclear stress test

Answer 34

1. Dilation of normal coronary arteries 2. Radioactive isotopes are injected 3. Done w/echo or radionuclide scintigraphy 4. For patients unable to tolerate other types of stress tests

Question 35

Geriatric considerations (4)

Answer 35

 Diminished pain transmission: may not exhibit typical pain  Often no symptoms-silent MI  CAD diagnosis: pharmacologic stress test and cardic cath lab  Use medications cautiously: increased risk of adverse reactions

Question 36

causes of acute coronary syndrome (5)

Answer 36

1. Atherosclerosis 2. Emboli 3. Blunt trauma 4. Spasm 5. Aortic dissection

Question 37

2 types of MI

Answer 37

STEMI and NSTEMI

Question 38

Pt has s/s ACS with an ST elevation.. what do they have?

Answer 38

STEMI

Question 39

Pt has s/s ACS with elevated troponin and normal ECG..what is it?

Answer 39

NSTEMI

Question 40

Pt has s/s ACS with normal troponin and normal ECG..what is it?

Answer 40

UAP

Question 41

Is a STEMI caused by a total block or partial block?

Answer 41

total

Question 42

AMI symptoms (9)

Answer 42

```  Midsternal chest pain  SOB  Pale and diaphoretic  Nausea and vomiting  Dysrhythmias  Dyspnea, tachypnea, hypotension  Syncope  Feeling of impending doom  Anxious/restless ```

Question 43

AMI midsternal chest pain characteristics (3)

Answer 43

1. Severe, crushing, and squeezing pressure 2. May radiate 3. Unrelieved with nitrates

Question 44

women s/s AMI (9)

Answer 44

```  Women may have atypical S/SX:  Fatigue  SOB  Diaphoresis  Indigestion  Arm/shoulder pain  Upper back  N/V  Jaw pain  SILENT MI - may have No S/S in the presence of ECG changes and increased troponin level ```

Question 45

normal troponin levels

Answer 45

< 0.04 ng/ml

Question 46

AMI Labs--> troponin characteristics

Answer 46

* Elevated within a few hours of heart damage and remain elevated for up to two weeks * A rise and/or fall trend: heart attack

Question 47

AMI Labs--> CK-MB characteristics (4)

Answer 47

* Appears 4-6 hours after symptom onset * Peaks at 24 hours * Returns to normal in 48-72 hours. * May be of use in case of reinfarction (rises again)

Question 48

AMI Labs --> Myoglobin

Answer 48

* Typically rises 2-4 hours after onset of infarction * Peaks at 6-12 hours * Returns to normal within 24-36 hours

Question 49

AMI interventions --> what to do first

Answer 49

MONA!! Morphine, oxygen, nitroglycerin, ASA

Question 50

AMI interventions --> what is done after MONA (4)

Answer 50

- Beta blocker - ACE inhibitor within 36 hours - anticoag w/ heparin and platelet inhibitors - statin

Question 51

Nursing care: ER Chest pain -->. assessment

Answer 51

CV, respiratory (crackles), allergies to dye or shellfish, ED meds

Question 52

What needs to be closely monitored for a patient on IV drip nitrgoglycerin

Answer 52

BP (hypotension may occur)

Question 53

CODE STEMI

Answer 53

- 12 lead ECG within 10 mins of arrival - activate code STEMI - less than or equal to 12 hours since symptom onset: stat trop, MONA, prepare for cath lab

Question 54

AMI Complications (7)

Answer 54

```  Dysrhythmias  Sudden death  Heart failure  Cardiogenic shock  Ventricular aneurysm or rupture  Aneurysm  Papillary muscle dysfunction or rupture ```

Question 55

door to cath lab time frame

Answer 55

90 min

Question 56

door to fibrolytics (needle) time frame

Answer 56

30 min

Question 57

when can PCI or thrombolytic therapy be used?

Answer 57

less than 12 hours of onset of pain

Question 58

when is thrombolytic therapy used instead of PCI?

Answer 58

if PCI is unavailable

Question 59

PCI interventions --> intracoronary stenting (4)

Answer 59

* Metal mesh to keep vessel open & prevent restenosis * Drug-eluting option to minimize formation of thrombi or scar tissue * ASA indefinitely * Anti-platelet drug clopidogrel (Plavix) for 1 year

Question 60

post-catheterization care for groin approach

Answer 60

• Lay flat 4-6 hours depending on intervention (may require reverse Trendelenberg)

Question 61

post-cath care --> radial approach

Answer 61

2-4 hours immbolized hand (TR band): focused assessment?  bleeding, neurovascular assessment (Sensation, Movement, Circulation)

Question 62

Post cath general care (3)

Answer 62

 Monitor for vascular hemostatic device and site for bleeding or hematoma  Monitor VS, patient, pulses: neurouvascular assessment  May be discharged in 6 to 8 hours; depends on diagnosis and procedures done in catheterization laboratory

Question 63

If interventional Cardiac cath lab unavailable or patient not candidate --> fibrinolysis ....nursing interventions (6)

Answer 63

```  Type and crossmatch blood  3 large bore IV’s  Cardiac monitor  Administer < 12 h from event  Follow with heparin  Monitor for s/s of bleeding ```

Question 64

when is someone a candidate for CABG?

Answer 64

 At least 70% occlusion or any coronary artery or 50% of left main coronary artery

Question 65

CABG indications (4)

Answer 65

* Alleviation of angina not controlled by PCI * Left main artery stenosis or multivessel disease * MI, dysrhythmias or heart failure * Complications from unsuccessful PCI

Question 66

increased mortality rate from CABG associated with: (6)

Answer 66

* Left ventricle dysfunction * Emergency surgery * Age * Gender (female) * Number of diseased vessels * Decreased EF with CHF

Question 67

CABG Complications (5)

Answer 67

- dysrhythmias - low CO - pericardial tamponade - hypovolemia - shock

Question 68

Pericardial tamponade causes ____

Answer 68

low CO

Question 69

Pericardial tamponade: BECKS TRIAD

Answer 69

- distended neck veins - muffled heart sounds - hypotension

Question 70

pericardial tamponade --> ECG Changes

Answer 70

causes electrical alternans

Question 71

if pt on heparin drip what lab needs to be monitored

Answer 71

APTT

Question 72

if patient on warfarin what lab needs to be monitored?

Answer 72

INR